Health inspection·January 24, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for resident abuse. The facility failed to prevent Resident #1 from being physically abused by MA D who hit Resident #1 on the face during patient care on 11/10/2024. The noncompliance was identified as past noncompliance. The noncompliance began on 11/10/2024 and ended on 11/11/2024. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of experiencing and enduring abuse causing a decreased quality of life. Findings included: Record review of Resident#1's face sheet dated 01/24/2025, reflected a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had a diagnosis of Unspecified Dementia, Moderate, With Agitation (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Record review of Resident #1's quarterly MDS assessment, dated 06/26/2024, reflected a BIMS score of 1 out of 15, which indicated the severe cognitive impairment. Further review of Resident #1's MDS reflected the resident needed assistance with ADL care. The MDS did not indicate Resident #1 had a history behaviors experience of hallucinations, or the expression of false beliefs (delusions). Record review of Resident#1's, undated, comprehensive care plan reflected a focus area initiated on 11/08/2024, Resident #1 had impaired cognitive function or impaired thought processes related to diagnosis of Dementia. Interventions: Engage the resident in simple, structured activities that avoid overly demanding tasks. The resident had a history of trauma that may have a negative impact. The trauma is related to: a negative interaction with staff member. Goal: Maintain resident's safety and integrity during post trauma episode, using appropriate interventions. Intervention: If the resident has escalated, if possible do not touch the resident unless necessary for resident's or others safety. Two staff members while providing care. Date Initiated: 11/11/2025. Record review of the provider investigation report dated 11/10/2025 revealed MA D's written statement read in part At 2:23a.m, I heard someone yelling mama I went and checked all the rooms to see who Page 1 of 3 675922 675922 01/24/2025 Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was calling out for help. It was Resident #1. I walked in the room to find her on the floor she was lying flat on her face and her right leg was bent. I called out for the nurse a couple times in the meantime CNA J, and I went back to the room. Resident #1 was still yelling mama we told her we had to wait for the nurse the nurse came asked her was she hurt Resident # 1 said her face and leg hurt me and CNA J started to position her to get her off the floor and she got upset and said to leave her alone because the two boys in the corner would get her up. We told her we would help her. Resident #1 started swinging as we lifted her from the floor. My head was down, and the tip of her hand brushed across my glasses. We got her in bed, and I said you can't be upset. We are trying to help you Record review of LVN C written statement dated 11/10/204 read in part November 10, 2024, at approximately 2:30 a.m. Resident#1 was found lying on her abdomen and her head facing towards the wall resident one did not appear in any distress. Assessment completed Resident#1 was returned to her bed by CNA J and MA Resident#1 was waving her arms in the air trying to be left alone. Resident #1 managed to hit MA D in the face. As a reaction MA D hit Resident#1 in her face Record review of CNA J's written statement dated 11/10/2024 read in part On Saturday night I was called to help MA pick Resident # 1 off the ground we waited until LVN C completed her assessment MA and I proceeded to pick up Resident # 1 She started swinging her hand trying to fight us Resident # 1 hit MA D in the face Resident # 1 was slapped back by MA D Observation and interview on 01/24/2025 at 5:00 p.m., Resident #1 was in bed, and she was dressed in her casual clothes. Resident #1 was not able to say if the staff was abusive to her. Resident #1 was a poor historian. During an interview on 01/24/2025 at 5:30 p.m., the DON stated there was an incident on 11/10/2024 with Resident #1 when MA D along with other staff was attempting to assist the resident off the ground back to bed. At this time the resident proceeded with slapping MA D across the face. The charge nurse witnessed MA D reacted and returned the slap to the resident. DON stated there was no reason for MA D to physically abuse Resident #1. DON stated the Administrator notified by the charge nurse of the incident on 11/10/2024. She stated MA D was suspended immediately on 11/10/2024, pending the facility's investigation. During interviews on 01/24/2025 between 12:47 a.m. and 4:50 p.m., (LVN W, CNA T, and MA C) from day shift were interviewed All staff interviewed were able to verbalize understanding of abuse/neglect in-services received. During an interview on 01/22/2025 at 6:00 p.m., the Administrator stated the facility had QAPI meeting about the incident; staff was in-serviced on abuse/neglect; safe surveys with residents; and the DON would train new staff upon hire on abuse/neglect. Record review reflected the following action were implemented by the facility: On 11/10/2024 immediately after the incident Resident #1 was assessed for pain/Injury/emotional distress No pain or injury noted; however resident did appear upset per charge nurse. The three staff members (MA D, LVN C, and CNA J) involved were suspended on 11/10/2024, pending facility's investigation. Incident reported to HHSC. 675922 Page 2 of 3 675922 01/24/2025 Parkview Manor Nursing and Rehabilitation 206 N Smith St Weimar, TX 78962

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/1 in servicing regarding reporting of abuse and neglect provided to staff members on 11/10/24 by Administrator. Law enforcement was notified by Administrator on 11/10/24. Resident #1 medical provider and responsible party was made aware of incident on 11/10//24 by Administrator. Risk management assessments completed for all residents on 11/10/24 by DON. Ad hoc QAPI completed on 11/10/24 with IDT team. In servicing initiated on Abuse and neglect on 11/10/24 by Administrator. In servicing initiated on Handling aggressive behaviors by DON 11 /11 /24. Trauma informed care assessment completed by charge nurse on 11/10/24. Resident #1 revised care plan for trauma informed care completed on 11 /11 /24. Resident #1 referred to psych services by DON on 11 /11 /24. Follow up assessment on Resident #1 completed on 11 /11 /24. No indication of pain and emotional distress was noted. State Surveyor verified the following: Record review of MA D employee file reflected the following: DOH: 06/21/2024 and MA D was training on abuse and neglect upon hire. Criminal background checks completed 07/09/2024. HHS check completed 06/28/2024. DOT: 11/10/2024 due to substantiated allegation of physical of abuse. The three staff ((LVN C, CNA J, and MA D) had previously had abuse and neglect training as well as behavior management for residents training prior to 11/10/2024. EMR/Criminal background/License check were current for three staff members (LVN C, CNA J, and MA D) involved. The facility policy on abuse dated 03/09/2018, reflected in part The resident has the right to be free from abuse Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, . The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, . and situations that may constitute abuse or neglect to any resident in the facility Physical Abuse: Includes, hitting, slapping, punching, and kicking. It also includes controlling behavior through corporal punishment 675922 Page 3 of 3